The ASC request for certification form
is utilized as an application for facilities wishing to participate
in the Medicare program as an ASC. This form initiates the process
of obtaining a decision as to whether the conditions of coverage
are met. It also promotes data retrieval from the Online Data Input
Edit (ODIE system, a subsystem of the Online Survey Certification
and Report (OSCAR) system by the Centers for Medicare and Medicaid
Services (CMS) Regional Offices (RO)). The ASC report form is an
instrument used by the State survey agency to record data
collection in order to...
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.